A healthier heartland – bridging America’s urban-rural divide

Jan 25, 2018 - reading time 6 mins

By Robin Warshaw

Writer | Ghostwriter

Robin Warshaw writes about medicine, health care and social issues for publications, institutions and organizations. She is also the author of a book on acquaintance rape. She is based in Glenside, Pennsylvania.

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While their surroundings may vary, rural residents in the US share an important characteristic: overall, they have poorer health than their city-dwelling fellow citizens do.

The Great Smoky Mountains in Tennessee at dusk.

About 20% of the US population lives in a rural community, from coal country mountains, farms and oil fields to ranches and tribal lands. While their surroundings may vary, rural residents in the US share an important characteristic: overall, they have poorer health than their city-dwelling fellow citizens do.

That gap has developed from factors including access to care, continuity of treatment and costs. Rural communities have fewer physicians or other providers and fewer health facilities. Since 2010, 83 rural hospitals have closed and those that remain often have limited services. More than half of rural counties in the US now lack hospitals that can deliver babies.

People must travel significant distance, sometimes for hours, to see a doctor or receive treatment. Specialists, such as cardiologists, oncologists or psychiatrists, are in short supply. Rural areas have only 30 specialists per 100,000 people, compared to 263 specialists per 100,000 urban dwellers, according to the National Rural Health Association.

Due to distance, poverty, lack of transportation or having no insurance, rural residents often delay getting medical care. That can cause chronic conditions and diseases to worsen by the time they finally see a doctor. Outcomes show the US rural-urban health gap in stark terms: rates of diabetes, heart disease, stroke, certain cancers, opioid overdoses and suicide are higher in rural areas. In 2014, the urban death rate was 704.3 per 100,000 people while the rural death rate was 830.5 per 100,000.

However, digital and connected technologies are helping overcome these challenges. In some places, this is already happening and much-needed change is being delivered through telehealth or telemedicine programs. These innovations use video, digital, wireless and mobile networks, devices and tools to deliver health care, monitoring and education.

“If anything, digital technologies are tailor-made for the rural setting,” says Susan Dentzer, President and CEO of the Network for Excellence in Health Innovation, a health policy institute. She points to the work of the University of Virginia’s telehealth program, which connects rural patients with medical services in more than 60 subspecialties. The program has cut at least 16 million miles of travel for rural patients since it began in 1996.

The widening adoption of telemedicine can provide an answer to the provider and service shortages in rural areas. “From a technological perspective, all of this could happen,” Dentzer says.

A whole new model

Videoconferencing, tablets, smartphones, mobile apps and wearables with biosensors will all be involved in these changes.

The only thing this model of health care really requires is an internet connection.

Leslie Saxon

MD, of the Center for Body Computing at the University of Southern California.

The tools enable health activities many rural communities need, including patient examinations, consultations with specialists, chronic disease management, self-monitoring, radiological imaging, transfer of records, and advanced learning for medical professionals. Patients take part at local clinics, community health centers or at home. The growth of retail health care clinics, such as those inside CVS or Walmart stores, could expand telemedicine in underserved and rural areas, Dr. Saxon says.

Real-time or synchronous delivery makes it possible for a patient in a rural location to have a remote visit with a doctor or nurse at a larger urban hospital. It also enables consultation between providers in different areas. “Store-and-forward” is an asynchronous method that compiles medical records and images before sending them on for analysis.

Remote patient monitoring provides observation of a person’s health condition without an office visit. Some implantable medical devices gather and send information and wearables measure a patient’s condition in real time, sending that data for evaluation.

A remote monitoring program from the Center for Telehealth at the University of Mississippi Medical Center has helped rural residents with type 2 diabetes lower their blood sugar levels. Patients use tablets to upload their data via a videoconferencing link. The program also remotely monitors other conditions that are common in rural areas, such as heart failure and hypertension.

“We’re building out solutions for these things all the time,” Dr. Saxon says. “They can be anything from a simple smartphone application that helps you manage your blood pressure to on-demand access 24/7 to a health care provider, either a real one or a virtual or human voice assistant.”

Overcoming the challenges

Although development of technology-assisted services and tools is thriving, public and private health insurers vary in what they will cover. However, as insurance models move from traditional “fee for service” to “value-based” structures, health systems and insurers are recognizing that bringing services near to where patients live is both cost-effective and improves outcomes.

High-speed broadband coverage, which of course is the backbone for all this technology, continues to be problematic in some rural areas. According to the Federal Communications Commission (FCC), 39% of people in US rural communities don’t have access to broadband, compared to only 4% of urban residents.

In January 2018, a presidential executive order eased the permit process for rural broadband access but did not offer funding. Congress is working on legislation, but whether private companies will make broadband investments in thinly populated rural areas without federal funding remains to be seen.

Concerns about costs and insurance reimbursements persist, yet the desire for change is there. In a 2016 report from the Healthcare Information and Management Systems Society (HIMSS), more than half of US hospitals surveyed used three or more connected health technologies and almost half planned to add more. According to the 2017 Future Health Index, nearly three quarters (73%) of healthcare professionals view connected care technology as important in improving the prevention of medical issues.

Medicare, the federal health insurance program for people aged 65 and over (and some younger people with disabilities), covers a few telemedicine options under its fee-for-service structure, but only for those living in certain rural areas. Patients in managed-care Medicare plans have wider telehealth coverage. As of 1 January 2018, Medicare began covering remote patient monitoring for all beneficiaries, a change that is likely to broaden technology use. Medicare readmission penalties also mean there’s an incentive to use telemedicine to keep patients healthier after hospital discharge.

State laws govern telehealth coverage for Medicaid, health insurance for those with financial need, and private insurers covering employers and individuals. Those rules vary by state.

Dr. Saxon believes the cost-to-value of technology solutions will promote wider adoption of mobile and connected tools, services and software. “What seems like an expense of a $600 smartphone and maybe a smartwatch and a stable data plan actually ends up saving a ton of money compared to even one ER visit,” she says. “People are tending to look at this in a much smarter way, much less traditionally and much more holistically.